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Form 990Department of the TreasuryInternal Revenue service
1,17)
Return of Organization Exempt From Income TaxUnder section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except black lung
benefit trust or private foundation)
► The organization may have to use a copy of this return to satisfy state reporting requirements
OMB No 1545-0047
2005
A For the 2005 calendar year, or tax year beginning May 1 , 2005, and ending A ril 30, , 20 06
B Check if applicable Please C Name of organization D Employer identification number
elabelaelaorEl Address changes Fletcher Allen Health Care Auxiliary 23 7003241
El Name change print or Number and street (or P 0 box if mail is not delivered to street address) Room/suite E Telephone number
q Initial return see111 Colchester Avenue ( 802 ) 847-1800
q Final returnSpecificmscruo- Ci ty town, state or count ry,^ and ZIP + 4 F Accounting method q Cash V] Accrual
q Amended returnbons. Burlington , VT 04501 q Other (specify) ►
q Application pending • Section 501 (c)(3) organizations and 4947 (a)(1) nonexempt charitable H and I are not applicable to section 527 organizations
ff ? q ®trusts must attach a completed Schedule A (Form 990 or 990- EZ) Yes NoH(a ) Is this a group return for a iliates
G Website : ► H(b) If "Yes," enter number of affiliates ► ...............
H(c) Are all affiliates included9 q Yes q No
J Organization type (check only one) ► ® 501(c) ( 3 ) i (insert no) q 4947(a)(1) or q 527 (If "No," attach a list See instructions)
K Check here ► q if the organization's gross receipts are normally not more than $25,000 TheH(d) Is this a separate return filed by an
? q Yes ® Norulinor anization covered b a roubut if the organization chooses to file a return beorganization need not file a return with the IRSgg y g p,,
sure to file a complete return Some states require a complete return. I Group Exemption Number ►
M Check ► ® if the organization is not required
L Gross receipts Add lines 6b, 8b, 9b, and 10b to line 12 ► 851,255 to attach Sch B (Form 990, 990-EZ, or 990-PF)
Revenue . Exnenses . and Chanaes in Net Assets or Fund Balances (See the instructions.)
I Contributions, gifts, grants, and similar amounts received:
a Direct public support . . . . . . . . . . . . is 0
upport . . . . . . . . . . . . 1b
GE tr tent ntrlbutlons (grants) isCe^
a through ic) (cash $ noncash $ ) id 0
line 93)evenue including government fees and contracts (from Part VII 2 250,946,
Q s and assessments 3 3 , 358
gs and temporary cash investmentsoIntereston 4 253. . . . . . . . . .
terest from securities 5 0. . . . .6a
b Less: rental expenses . . . . . . . . . . 6b
c Net rental income or (loss) (subtract line 6b from line 6a) 6c 0. . . . . . .7 Other investment income (describe ► 7 0
8a Gross amount from sales of assets other(A) Securities (B) Other
than inventory 0 8a 0cc . . . . . . . .
b Less cost or other basis and sales expenses 0 8b 0.
c Gain or (loss) (attach schedule) 0 8c 0. . .
d Net gain or (loss) (combine line 8c columns (A) and (B)) 8d 0, . . . . . . . . . . .
9 Special events and activities (attach schedule) If any amount is from gaming , check here ► q
a Gross revenue (not including $ of
contributions reported on line la) . . . . . . . 9a 3,811
b Less. direct expenses other than fundraising expenses 9b 10,946
c Net income or (loss) from special events (subtract line 9b from line 9a) 9c (7,135)
10a Gross sales of inventory, less returns and allowances . 10a 586,311
b Less: cost of goods sold . . . . . . . . 10b 336,428
c Gross profit or (loss) from sales of inventory (attach schedule) (subtract line 10b from line 10a) 10c 249,883
11 Other revenue (from Part VII line 103) . . . . . . . . . . . . . 11 6,576,12 Total revenue (add lines 1d, 2, 3, 4, 5, 6c, 7, 8d, 9c, 10c, and 11) . 12 503,881
column ( B))ram services (from line 4413 Pro 13 488,275. . . . . . . . . . . . .,g
column (C))14 Management and general (from line 44 14 7,660, . . . . . . . . . .
column (D))(from line 4415 Fundraisin 15 1,083Q.ul
. . . . . . . . . . . . . . ,,g
16 Payments to affiliates (attach schedule) . . . . . . . . . . . . . 16 0
17 Total expenses (add lines 16 and 44, column (A)) 17 497,018
18 Excess or (deficit) for the year (subtract line 17 from line 12) 18 65863. . . . . . . . .
column (A))19 Net assets or fund balances at beginning of year (from line 73 19 157,212, . . . .
20 Other changes in net assets or fund balances (attach explanation). . . . . . 20 0*,= 21 Net assets or fund balances at end of year (combine lines 18, 19, and 20) 21 164,075
For Privacy Act and Paperwork Reduction Act Notice , see the separate instructions . Cat No 11282Y Form 990 (2005)
J?
" Fletcher Allen Health Care Auxiliary 23-7003241Form 990 (2005) Page 2
1111017111111 Statement of All organizations must complete column (A). Columns (B), (C), and (D) are required for section 501(c)(3) and (4)
Functional Expenses organizations and section 4947(a)(1) nonexempt charitable trusts but optional for others (See the instructions.)
Do not include amounts reported on line6b, 8b, 9b, 10b, or 16 of Part I.
Tota l (B) Programservices
(C) Managementand general (D) Fundraising
22 Grants and allocations (attach schedule)
(cash $ Stmt 2 noncash $ )If this amount includes foreign grants, check here ► q
22133,394 133,394
23 Specific assistance to individuals (attachschedule) 23 0
24 Benefits paid to or for members (attachschedule) 24 0
directors25 Compensation of officers etc. 25 0, ,
26 Other salaries and wages 26 203,078 203,078
27 Pension plan contributions 27 0
28 Other employee benefits 28 52,238 52,238
29 Payroll taxes 29 030 Professional fundraising fees 30 0. .31 Accounting fees 31 530 530
32 Legal fees 32 0
33 Supplies 33 11,379 11,379
34 Telephone 34 1,347 1,347
35 Postage and shipping 35 193 193
36 Occupancy 36 57,883 57,883
37 Equipment rental and maintenance 37 1,650 1,650.
38 Printing and publications 38 492 492
39 Travel 39 2,440 2,440
conventions and meetings30 Conferences 40 6,809 6,809, ,
41 Interest 41 0
42 Depreciation depletion etc. (attach schedule) 42 2,588 2,588 see statement 4, 5, and 6, ,43 Other expenses not covered above (itemize):a 43a 21,786 21,786
b Bushels of Baskets fundraiser 43b 1,083 1,083........ . .. . _
c Training & Education 43c 128 128- ................... ------
de 43e
f 43f
943g
44 Total functional expenses. Add lines 22through 43. (Organizations completingcolumns (B)-(D), carry these totals to lines13-15) 4 97,018 , 88,275 , ,660 , ,083
Joint Costs. Check ► q if you are following SOP 98-2.Are any joint costs from a combined educational campaign and fundraising solicitation reported in (B) Program services? ► q Yes ® No
If "Yes," enter (i) the aggregate amount of these joint costs $ ; (ii) the amount allocated to Program services $
(iii) the amount allocated to Management and general $ ; and (iv) the amount al located to Fundraising $
Form 990 (2005)
" Fletcher Allen Health Care Auxiliary 23-7003241Form 990 (2005) Page 3
J;MM Statement of Program Service Accomplishments (See the instructions.)
Form 990 is available for public inspection and, for some people, serves as the primary or sole source of information about aparticular organization. How the public perceives an organization in such cases may be determined by the information presentedon its return. Therefore, please make sure the return is complete and accurate and fully describes, in Part. III, the organization'sprograms and accomplishments.
What is the organization's primary exempt purpose? ► - Statement #7 Program Service--•------------------------•---------------- Expenses
All organizations must describe their exempt purpose achievements in a clear and concise manner. State the number ( Required for 501(c)(3) andof clients served, publications issued, etc. Discuss achievements that are not measurable (Section 501(c)(3) and (4) (4) orgs. and 49471a1(1)
organizations and 4947(a)(1) nonexempt charitable trusts must also enter the amount of gra nts and allocations to others)trusts, oth ost)nal or
a Pandora 's Box and vairous other funds for patients at Fletcher Allen Health Care , a not for profit
health system
Statement #8 .
------------------------------------------------------------------------------------------------------------------------
-- -ran---ts--an- d---allocations--------•--------•------------------ -If--this-- -amount-----in----clud-e--s foreign r
•---,ants---check---
here- --
111',--
33,394--') q(G $ 1 '3'3' ,'3-9'4',')' 488
b ........................................................................................................................
------------ --- - -----------•------------------------------ ----- ------- -- --- ------------------------ --(Grants and allocations $ ) If this amount includes foreign grants, check here ► q
C ------------------------------------•--------------------------------------------------------•----------------------•---
------------------------------------------------------------------------------------------------------------------------
------. ---- - ------ - --9- ---- - -•-- ---- -- qGrants and allocations $ ) If this amount includes forei n rants, check here ►
d ------------------------------------------------------
-------- ---- ---------- - - • ------- - ------ - ---- -•---- - ---- ---- --(Grants and allocations $ ) If this amount includes foreign grants, check here ► q
e Other program services (attach schedule)
(Grants and allocations $ ) If this amount includes foreign grants, check here ► q
f Total of Program Service Expenses (should equal line 44, column (B), Program services) ► 488,275
Form 990 (2005)
^1e^cher (^I1eh l^eglih dare AUx1II'al Q3- r1003D.4)
Form 990 (2005) Page 4
Balance Sheets (See the instructions.)
Note : Where required, attached schedules and amounts within the description (A) (B)column should be for end-of-year amounts only Beginning of year End of year
45 Cash-non-interest-beanng 129,744 45 146,326. . . . . . . . . . . . . .
46 Savings and temporary cash investments . 46. . . . . . . .
47a Accounts receivable . . . . . . . 47a 466
b Less: allowance for doubtful accounts 47b 0 315 47c 466
48a Pledges receivable 1. . . . .
b Less: allowance for doubtful accounts 48b 0 48c 0
49 Grants receivable 49. . . . . . . . . . . . . . . . .
50 Receivables from officers, directors, trustees, and key employees
(attach schedule) 0 50 0. . . . . . . . . . . . . . .
51a Other notes and loans receivable (attach
schedule) . . . . . . . . . 51a
51bb Less allowance for doubtful accounts 0 Sic 0.
52 Inventories for sale or use 46, 669 52 55,833. . . . . . . . . . . .
53 Prepaid expenses and deferred charges 53. .
► q Cost q FMV54 Investments-securities (attach schedule) 0 54 0. .
55a Investments-land, buildings, and
equipment: basis . . . . . . . . 55a
b Less: accumulated depreciation (attach55bschedule) 0 55c 0. . . . . . . . . . .
56 Investments-other (attach schedule) 0 56
and equipment: basis57a Land buildings 57a. .
3i, 891., ,
b Less: accumulated depreciation (attach
schedule) 57b 27, 182 12,299 57c 9,709. . . . . . . .
58 Other assets (describe ► car seats ) 7,836 58 7,949-- - --------------------------------------
59 Total assets (must equal line 74). Add lines 45 through 58.. 196,863 59 220,283
60 Accounts payable and accrued expenses 18,137 60 33,484. . . . . . . . .
61 Grants payable 61. . . . . . . . . . . . . . . . .
62 Deferred revenue 62. . . . . . . . . . . . . . . .
d 63 Loans from officers, directors, trustees, and key employees (attach
schedule) 63. . . . . . . . . . . . . . . . . . .
64a Tax-exempt bond liabilities (attach schedule) 64a. . . . . .
b Mortgages and other notes payable (attach schedule) 0 64b 0. . . .65 Other liabilities (describe ► Statement #11------------------------- ) 21 , 514 65 22,724
66 Total liabilities . Add lines 60 through 65 39,651 66 56,208
Organizations that follow SFAS 117, check here ► 0 and complete lines
67 through 69 and lines 73 and 74.
0 67 Unrestricted 157,212 67 164,075c
. . . . . . . . . . . . . . . . .
68 Temporarily restricted 68
M
. . . . . . . . . . . . . . . .
69 Permanently restricted 69. . . . . . . . . . . . .
check here ► q andOrganizations that do not follow SFAS 117
U.
,
complete lines 70 through 74.
0 or current fundstrust principalital stock70 Ca 70, . . . . . . .,p
and equipment fundbuildingor land71 Paid-in or capital surplus 71,, ,
or other fundsaccumulated incomeendowment72 Retained earnings 72,,,
73 Total net assets or fund balances (add lines 67 through 69 or lines
Z 70 through 72;column (A) must equal line 19; column (B) must equal line 21) . . 157,212 73 164,075
74 Total liabilities and net assets/fund balances . Add lines 66 and 73. 196,863 74 220,283
Form 990 (2005)
11
Fletcher Allen Health Care Auxiliary 23-7003241Form 990 (2005) Page 5
Reconciliation of Revenue per Audited Financial Statements With Revenue per Return (See theinstructions.) N/A
and other support per audited financial statementsgainsa Total revenue a, ,
b Amounts included on line a but not on Part I, line 12:
1 Net unrealized gains on investments b1
2 Donated services and use of facilities b2
3 Recoveries of prior year grants b3
4 Other (specify)- ..............................................................b4
Add lines b1 through b4 b
c Subtract line b from line a cd Amounts included on Part I, line 12, but not on line a:
1 Investment expenses not included on Part I, line 6b d1
2 Other (specify) : ..............................................................d2
---------------------------------------------------------------------------------Add lines d1 and d2 d
e Total revenue (Part I, line 12). Add lines c and d ►MUMM Reconciliation of Expenses per Audited Financial Statements With Expenses p
e
er Return N/ A
a Total expenses and losses per audited financial statements a
b Amounts included on line a but not on Part I, line 17:
1 Donated services and use of facilities b1
2 Prior year adjustments reported on Part I, line 20 b2
3 Losses reported on Part I, line 20 b3
4 Other (specify) : ..............................................................b4
Add lines b1 through b4 b
c Subtract line b from line a c
d Amounts included on Part I, line 17, but not on line a:
1 Investment expenses not included on Part I, line 6b d1
2 Other (specify) : ..............................................................d2
---------------------------------------------------------------------------------Add Iines d1 and d2 d
e Total expenses (Part I, line 17). Add lines c and d e
Current Officers , Directors , Trustees , and Key Employees (List each person who was an officer, director, trustee,or key emolovee at any time dunna the year even if they were not compensated.) (See the instructions)
(B) (C) Compensation (D) Contributions to employee (E) Expense account(A) Name and address Title and average hours per (if not paid, enter benefd plans & deterred and other allowances
week devoted to position -0-. ) compensation p lans
Connie Westfall- ----- --------------------------------------------•-------- President as require 0 0 03 Eastman Farm Rd, Burlington, VT 05401
Diane Guild ---- Vice Pres as requirec 0 0 016 Andrews Avenue, So. Burlington, VT 05403
Anne Francis•------ ----------------------------------------- -- Treasurer as require 0 0 0274 Pine Haven Shores Ln, Shelburne, VT 05482
Gretchen Decker.............................. ...... . ................. . Corr Secretary as rec 0 0 0446 Terrace Drive, Williston, VT 05495
Ginny Burleson ____ _______________------------------------- - Rec Secretary as req 0 0 0, VT 05482Shelburne124 Martindale Rd,
Gail Gendron- ---- ----------------------------------------------------- Past Pres as require 0 0 0608 S. Beach Rd, So. Burlington, VT 05403
-
--------------------------------------------------------------
Form 990 (2005)
' Fletcher Allen Health Care Auxiliary 23-7003241
Form 990 (2005) Page 6
FOMEVA Current Officers, Directors , Trustees , and Key Employees (continued) Yes No
75a Enter the total number of officers, directors, and trustees permitted to vote on organization business at board
meetings ► --------- 6-----------
b Are any officers, directors, trustees, or key employees listed in Form 990, Part V-A, or highest compensated
employees listed in Schedule A, Part I, or highest compensated professional and other independent
contractors listed in Schedule A, Part II-A or II-B, related to each other through family or business
relationships? If "Yes," attach a statement that identifies the individuals and explains the relationship(s) 75b 3
c Do any officers, directors, trustees, or key employees listed in Form 990, Part V-A, or highest compensated
employees listed in Schedule A, Part I, or highest compensated professional and other independent
contractors listed in Schedule A, Part II-A or II-B, receive compensation from any other organizations, whether
tax exempt or taxable, that are related to this organization through common supervision or common control? 75c 3
Note . Related organizations include section 509(a)(3) supporting organizations.
If "Yes," attach a statement that identifies the individuals, explains the relationship between thisorganization and the other organization(s), and describes the compensation arrangements,including amounts paid to each individual by each related organization. _ . w 0
d Does the organization have a written conflict of interest policy? 75d 3
Former Officers, Directors, Trustees, and Key Employees That Received Compensation or Other Benefits (If any former
officer, director, trustee, or key employee received compensation or other benefits (described below) during the year, list that
person below and enter the amount of compensation or other benefits in the appropriate column See the instructions.)
(A) Name and address (B) Loans and Advances (C) Compensation(D) Contributions to employee
benefit plans & deferedcompensat ion plars
(E) Expenseaccount and other
allowances
NONE
--------------------------------------------------------------
--------------------------------------------------------------
Other Information (See the instructions. )
.
Yes No
" attach a detailedthe IRS? If "Yesl d tt t t tDid h i6 -,previous y repor e on any ac ivi y noe organization engage7 tdescri tion of each activit 76 3p y
es made in the organizing or governing documents but not reported to the IRS?77 Were an chan 77 3y g
If "Yes," attach a conformed copy of the changes.
ear covered bthe000 or more durinf $1h h l t d b8 D yg y,usiness gross income oe organization ave unre a e7 a id tthis return? 78a
" has it filed a tax return on Form 990-T for this year?b If "Yes 78b n,
" attachor substantial contraction during the year? If "Yestermination79 W id t n dissolutionth l -^,,io , ,as ere a iqu aa statement 79
80a Is the organization related (other than by association with a statewide or nationwide organization) through
t or nonexem tr x mt thff ttd ppo any o e e eicers, e c.,ies, trus ees, ocommon membership, governing bo
or anization? 80a 3g
b If "Yes," enter the name of the organization ► -----------------------------------------------------•-------------
-------------------------------------------------------and check whether it is q exempt or q nonexempt
81a Enter direct and indirect political expenditures. (See line 81 instructions .) 1 81a NONE_
b Did the organization file Form 1120-POL for this year? 81b 3
Form 990 (2005)
Fletcher Allen Health Care Auxiliary 23-7003241Form 990 (2005) Page 7
Other Information (continued) Yes No
82a Did the organization receive donated services or the use of materials , equipment , or facilities at no charge 3
or at substantially less than fair rental value? 82a
b If "Yes ," you may indicate the value of these items here . Do not include this
in Part I or as an ex ense in Part IInt p .as reveamoun ue(See instructions in Part III.) 82b 3
83a Did the organization comply with the public inspection requirements for returns and exemption applications? 83a
b Did the organization comply with the disclosure requirements relating to quid pro quo contributions? 83b 3
84a Did the organization solicit any contributions or gifts that were not tax deductible? 3
" did the organization include with every solicitation an express statement that such contributions orb If "Yes ^- J,gifts were not tax deductible? 84b
n
a Were substantially all dues nondeductible by members?or (6) organizations85 501 (c)(4) (5) 85a., ,
000 or less?b Did the organization make only in-house lobbying expenditures of $2 85b,
If "Yes" was answered to either 85a or 85b, do not complete 85c through 85h below unless the organization
received a waiver for proxy tax owed for the prior year.
c Dues , assessments , and similar amounts from members 85c N/A
d Section 162(e) lobbying and political expenditures 85d N/A
e Aggregate nondeductible amount of section 6033(e)(1)(A) dues notices 85e N/A
f Taxable amount of lobbying and political expenditures (line 85d less 85e) 8f N/A
g Does the organization elect to pay the section 6033(e) tax on the amount on line 85f?85g
n
h If section 6033(e)(1)(A) dues notices were sent , does the organization agree to add the amount on line 85f
to its reasonable estimate of dues allocable to nondeductible lobbying and political expenditures for then
following tax year?85h
86 501 (c)(7) orgs. Enter: a Initiation fees and capital contributions included on
.
line 12 86a N/A ,
b Gross receipts , included on line 12, for public use of club facilities 86b N/A
87 501 (c)(12) orgs. Enter : a Gross income from members or shareholders 87a N/A
b Gross income from other sources . (Do not net amounts due or paid to othersources against amounts due or received from them .) 87b N/A
88 At any time during the year , did the organization own a 50% or greater interest in a taxable corporation or
ulations sections 301 7701-2arate from the or anization under Redisre arded as sertn r hi r an entit .g gpp , o y gpa e s" complete Part IX7701-3? If "Yesand 301 88,.
89a 501 (c)(3) organizations . Enter : Amount of tax imposed on the organ izatio 'during the year under:
A; section 4955 N/Asection 4911 ► ................. N/A < section 4912 10 .................. (
b 501(c)(3) and 501(c)(4) orgs. Did the organization engage in any section 4958 excess benefit transactionduring the year or did it become aware of an excess benefit transaction from a prior year? If "Yes," attach no ea statement explaining each transaction 89b
c Enter: Amount of tax imposed on the organization managers or disqualified persons during the year
under sections 4912, 4955, and 4958 ► NONE
d Enter: Amount of tax on line 89c, above, reimbursed by the 'tion ► NONE3a 1
90a List the states with which a copy of this return is filed ► NONE
b Number of employees employed in the pay period that includes March 12, 2005 (Seeinstructions .) 190b
91a The books are in care of ► Anne Francis ----------------------------------- Telephone no. -) 985-3895_.........
Located at ► _?^4 Pine _Haven Shores Ln, Shelburne , VT _____- 05482ZIP + 4 ► ------
b At any time during the calendar year, did the organization have an interest in or a signature or other authority
over a financial account in a foreign country (such as a bank account, securities account, or other financial Yes No
account)? 91b 3
If "Yes," enter the name of the foreign country ► ................................................................
See the instructions for exceptions and filing requirements for Form TD F 90-22.1, Report of Foreign Bank
and Financial Accounts.
c At any time during the calendar year, did the organization maintain an office outside of the United States? 91c 3
If "Yes," enter the name of the foreign country ► ................................................................
92 Section 4947(a)(1) nonexempt charitable trusts filing Form 990 in lieu of Form 1041-Check here ► q
and enter the amount of tax-exempt interest received or accrued during the tax year ► 1 92 1 N/A
Form 990 (2005)
Fletcher Allen Health Care Auxiliary 23-7003241Form 990 (2005) Page 8
Analysis of Income-Producin g Activities (See the instructions.
Note: Enter gross amounts unless otherwise Unrelated business income Excluded by section 512, 513, or 514 (E)
indicated.
93 Program service revenue:
(A)Business code
(B)Amount
(C)Exclusion code
(D )Amount
Related orexempt function
income
a Portraits 03 242
b Car Seat Rentals 02 3,393
c Second Hand Shop 02 239,584
d Bushels of Baskets I Plant Sale 02 7,727
ef Medicare/Medicaid payments
g Fees and contracts from government agencies94 Membership dues and assessments 3,358
95 Interest on savings and temporary cash investments 14 253
96 Dividends and interest from securities
97 Net rental income or (loss) from real estate: a^ AM ''Ia debt-financed property
b not debt-financed property
98 Net rental income or (loss) from personal property99 Other investment income100 Gain or (loss) from sales of assets other than inventory
101 Net income or (loss) from special events 01 (7,135)
102 Gross profit or (loss) from sales of inventory 03 249,883
103 Other revenue : a Auxiliary Luncheons 6,576
bcd
eand (E))104 Subtotal (add columns (B) (D) `° 493,947 9,934, ,
105 Total (add line 104, columns (B), (D), and (E))Note: Line 105 plus line 1d, Part I. should equal the amount on line 1 2, Part I.
► 503,881
LiCIM Relationshi p of Activities to the Accomplishment of Exempt Purposes (See the instructions.)
Line No .V
Explain how each activity for which income is reported in column (E) of Part VII contributed importantly to the accomplishmentof the organization's exempt purposes (other than by providing funds for such purposes).
94 & 103 The Fletcher Allen Health Care Auxilia ry 's prima ry purpose is to support the mission of Fletcher Allen Health
Care, a not for profit , in providing acute health care service to the community regardless of the ability to pay .The dues charged to members of the auxilia ry as well as funds raised at reg ularly scheduled luncheons are partof the total dollars available to support FAHC , thus contributing to the organizations exempt purpose.
LEM Information Regarding Taxable Subsidiaries and Disregarded Entities (See the instructions.)A
Name, address, and EIN of corporation,partnership , or disregarded entity
Percentage ofownershi interest Nature
of activities Total (D)incomeEnd-op-year
assets
N/A % 0 0
% 0 0
% 0 00 0
90TW. Information Regarding Transfers Associated with Personal Benefit Contracts (See me instructions.)
(a) Did the organization , during the year, receive any funds, directly or Indirectly. to nav r mi rns on a r n l benefit contract? Yes No
(b) Did the organization, during the year, pay premiums, direNote: If "Yes" to (b), file Form 8870 and Form 4720 (see fnst
Under penalties of perjury, I declare that I hafe examined this return,and ief, it is true , correct, and eomplete eclaration of preparer
PleaseSign
nature of officerHere ' " w
Paid
Type or print name and title
Preparers 'signature
Preparer's'
Use OnlyFirm s name (or yoursif self-employed),address. and ZIP + 4
LL
SCHEDULE A Organization Exempt Under Section 501(c)(3)(Form 990 or 990-EZ) (Except Private Foundation) and Section 501(e), 501(f), 501(k), 501(n),
or 4947(a)(1) Nonexempt Charitable Trust
Department of the TreasurySupplementary Information-(See separate instructions.)
Internal Revenue service ► MUST be completed by the above organizations and attached to their Form 990 or 990-EZ
Name of the organization
Fletcher Allen Health Care
OMB NO 1545-0047
2005Employer identification number
23;7003241
Compensation of the Five Highest Paid Employees Other Than Officers, Directors , and Trustees(See oaae 1 of the instructions. List each one. If there are none. enter "None.")
(a) Name and address of each employee paid morethan $50,000
(b) Title and average hoursper week devoted to position (c) Compensation
(d) Contributions toemployee benefit plans &deterred compensation
(e) Expenseaccount and other
allowances
NONE
-------------------------------------------------------
--------------------------------------------------------
-------------------------------------------------------
-------------------------------------------------------
Total number of other employees paid over $50,000 ► NONE
n i Compensation of the Five Highest Paid Independent Contractors for Professional Services(See oaae 2 of the instructions. List each one (whether individuals or firms). If there are none, enter "None.")
(a) Name and address of each independent contractor paid more than $50,000 (b) Type of service (c) Compensation
NONE--------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------
Total number of others receiving over $50,000 for►professional services NONE " ffi
^^ Compensation of the Five Highest Paid Independent Contractors for Other Services(List each contractor who performed services other than professional services, whether individuals orfirms. If there are none, enter "None." See page 2 of the instructions.)
(a) Name and address of each independent contractor paid more than $50,000 (b) Type of service (c) Compensation
NONE
Total number of other contractors receiving over INONE$50,000 for other servi ces ►
For Paperwork Reduction Act Notice, see the Instructions for Form 990 and Form 990-EZ . Cat No 11285E Schedule A (Form 990 or 990-EZ) 2005
Fletcher Allen Health Care Auxiliary 23-7003241
Schedule A (Form 990 or 990-EZ) 2005 Page 2
Statements About Activities (See page 2 of the instructions.) Yes No
1 During the year, has the organization attempted to influence national, state, or local legislation, including any
attempt to influence public opinion on a legislative matter or referendum? If "Yes," enter the total expenses paidor incurred in connection with the lobbying activities ► $ 0 (Must equal amounts on line 38,
V/
Part VI-A, or line i of Part VI-B.) 1
Organizations that made an election under section 501(h) by filing Form 5768 must complete Part VI-A. Otherorganizations checking "Yes" must complete Part VI-B AND attach a statement giving a detailed description ofthe lobbying activities.
2 During the year, has the organization, either directly or indirectly, engaged in any of the following acts with anysubstantial contributors, trustees, directors, officers, creators, key employees, or members of their families, orwith any taxable organization with which any such person is affiliated as an officer, director, trustee, majorityowner, or principal beneficiary? (If the answer to any question is "Yes," attach a detailed statement explaining thetransactions.)
exchange or leasing of property?a Sale 2a 3, ,
b Lending of money or other extension of credit? 2b 3
c Furnishing of goods services, or facilities? 2c 3,
d Payment of compensation (or payment or reimbursement of expenses if more than $1,000)? 2d 3
e Transfer of any part of its income or assets? Statement #9 2e 3
3a Do you make grants for scholarships, fellowships, student loans, etc.? (If "Yes," attach an explanation of how
you determine that recipients qualify to receive payments.) Statement #10 3a
b Do you have a section 403(b) annuity plan for your employees? 3b 3
did the organization receive a contribution of qualified real property interest under section 170(h)?c During the year 3c 3,
4a Did you maintain any separate account for participating donors where donors have the right to provide advice on 3
the use or distribution of funds?b Do you provide credit counseling, debt management, credit repair, or debt negotiation services? 4b 3
Reason for Non-Private Foundation Status (See pages 3 through 6 of the instructions.)
The organization is not a private foundation because it is: (Please check only ONE applicable box.)
5 q A church, convention of churches, or association of churches Section 170(b)(1)(A)(i).
6 q A school. Section 170(b)(1)(A)(ii). (Also complete Part V.)
7 q A hospital or a cooperative hospital service organization. Section 170(b)(1)(A)(ui).
8 q A Federal, state, or local government or governmental unit. Section 170(b)(1)(A)(v).
9 q A medical research organization operated in conjunction with a hospital. Section 170(b)(1)(A)(ui). Enter the hospital ' s name, city,
and state ► ...........................................................................................................................10 q An organization operated for the benefit of a college or university owned or operated by a governmental unit. Section 170(b)(1)(A)(Iv).
(Also complete the Support Schedule in Part IV-A.)
1la q An organization that normally receives a substantial part of its support from a governmental unit or from the general public. Section
170(b)(1)(A)(vi) (Also complete the Support Schedule in Part IV-A.)
1lb q A community trust. Section 170(b)(1)(A)(w). (Also complete the Support Schedule in Part IV-A.)
12 q An organization that normally receives : (1) more than 33'/3% of its support from contributions, membership fees, and gross receipts
from activities related to its charitable, etc., functions-subject to certain exceptions, and (2) no more than 33'/3% of its support
from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the
organization after June 30, 1975. See section 509(a)(2). (Also complete the Support Schedule in Part IV-A.)
13 ® An organization that is not controlled by any disqualified persons (other than foundation managers) and supports organizationsdescribed in: (1) lines 5 through 12 above; or (2) sections 501(c)(4), (5), or (6), if they meet the test of section 509(a)(2). Checkthe box that describes the type of supporting organization: ► q Type 1 q Type 2 q Type 3
Provide the following information about the supported organizations. (See page 6 of the instructions.)
(a) Name(s) of supported organization(s)(b) Line number
from above
Fletcher Allen Health Care 7
14 q An organization organized and operated to test for public safety. Section 509(a)(4). (See page 6 of the instructions.)
Schedule A (Form 990 or 990-EZ) 2005
, Fletcher Allen Health Care Auxiliary 23-7003241Schedule A (Form 990 or 990-EZ) 2005 Page 3
' • Support Schedule (Complete only if you checked a box on line 10, 11, or 12.) Use cash method of accounting.
Note: You may use the worksheet in the instructions for convertina from the accrual to the cash method of accounting. N/A
Calendar year (or fiscal year beginning in) ► (a) 2004 (b) 2003 (c) 2002 (d) 2001 (e) Total
15 Gifts, grants, and contributions received. (Do
not include unusual grants. See line 28.). 0
16 Membership fees received 0
17 Gross receipts from admissions, merchandisesold or services performed, or furnishing offacilities in any activity that is related to theorganization's chartable, etc., purpose 0
18 Gross income from interest, dividends,amounts received from payments on securitiesloans (section 512(a)(5)), rents, royalties, andunrelated business taxable income (lesssection 511 taxes) from businesses acquiredby the organization after June 30, 1975 0
19 Net income from unrelated business
activities not included in line 18 0
20 Tax revenues levied for the organization'sbenefit and either paid to it or expended onits behalf 0
21 The value of services or facilities furnished tothe organization by a governmental unitwithout charge. Do not include the value ofservices or facilities generally furnished to thepublic without charge 0
22 Other income Attach a schedule. Do not
include gain or (loss) from sale of capital assets 0
23 Total of lines 15 through 22 0 0 0 0 0
24 Line 23 minus line 17 0 0 0 0 0
25 Enterl%ofline23 0 0 0 0
line 24 ►26 Organizations described on lines 10 or 11 : a Enter 2% of amount in column (e) 26a 0,
b Prepare a list for your records to show the name of and amount contributed by each person (other than ah 2004 exceeded theifts for 2001 throuhose totaltion)t bli l dt l t g gorganiza wuni or pu c y suppor egovernmen a
Do not file this list with your return . Enter the total of all these excess amounts ►amount shown in line 26a 26b.
column (e) ►c Total support for section 509(a)(1) test: Enter line 24 26c 0,
d Add: Amounts from column (e) for lines: 18 0 19 0
22 0 26b 0 ► 26d 0
e Public support (line 26c minus line 26d total) ► 26e 0
f Public support percentage (line 26e (numerator) divided by line 26c (denominator)) ► 26f 0.00 %
27 Organizations described on line 12 : a For amounts included in lines 15, 16, and 17 that were received from a "disqualifiedperson," prepare a list for your records to show the name of, and total amounts received in each year from, each "disqualified person."Do not file this list with your return . Enter the sum of such amounts for each year:
(2004) .......................... (2003) .......................... (2002) .......................... (2001) ..........................b For any amount included in line 17 that was received from each person (other than "disqualified persons"), prepare a list for your records to
show the name of, and amount received for each year, that was more than the larger of (1) the amount on line 25 for the year or (2) $5,000.(Include in the list organizations described in lines 5 through 11 b, as well as individuals.) Do not file this list with your return . After computingthe difference between the amount received and the larger amount described in (1) or (2), enter the sum of these differences (the excessamounts) for each year:
(2004) .......................... (2003) .......................... (2002) -------------------------- (2001) --------------------------
c Add: Amounts from column (e) for lines: 15 16
17 20 21 ► 27c
d Add: Line 27a total, and line 27b total ► 27d
e Public support (line 27c total minus line 27d total) ► 27e
f Total support for section 509(a)(2) test: Enter amount from line 23, column (e) ► 27f I
g Public support percentage (line 27e (numerator) divided by line 27f (denominator)) ► 27g 0.00 %
h Investment income percentage (line 18 , column (e) (numerator) divided by line 27f (denominator)). ► 27h 0.00
28 Unusual Grants : For an organization described in line 10, 11, or 12 that received any unusual grants during 2001 through 2004,
prepare a list for your records to show, for each year, the name of the contributor, the date and amount of the grant, and a brief
description of the nature of the grant. Do not file this list with your return . Do not include these grants in line 15.
Schedule A (Form 990 or 990-EZ) 2005
Fletcher Allen Health Care Auxiliary 2307003241Schedule A (Form 990 or 990-EZ) 2005 Page 4
Private School Questionnaire (See page 7 of the instructions.)
(To be completed ONLY by schools that checked the box on line 6 in Part IV) Not A licable
29 Does the organization have a racially nondiscriminatory policy toward students by statement in its charter, bylaws, Yes No
other governing instrument, or in a resolution of its governing body? 29
30 Does the organization include a statement of its racially nondiscriminatory policy toward students in all its
brochures, catalogues, and other written communications with the public dealing with student admissions, -= ' -programs, and scholarships? 30
31 Has the organization publicized its racially nondiscriminatory policy through newspaper or broadcast media during
the period of solicitation for students, or during the registration period if it has no solicitation program, in a waythat makes the policy known to all parts of the general community it serves? 31
If "Yes," please describe; if "No," please explain. (If you need more space, attach a separate statement.)
------------------------------------------------------------------------------------------------------------------------32 Does the organization maintain the following:
a Records indicating the racial composition of the student body, faculty, and administrative staff? 32a
b Records documenting that scholarships and other financial assistance are awarded on a racially nondiscriminatory
basis? 32b
c Copies of all catalogues, brochures, announcements, and other written communications to the public dealing
with student admissions, programs, and scholarships? 32c
d Copies of all material used by the organization or on its behalf to solicit contributions? 32d
If you answered "No" to any of the above, please explain. (If you need more space, attach a separate statement.)
33 Does the organization discriminate by race in any way with respect to: "
a Students' rights or privileges? Ma
b Admissions policies? IMo
c Employment of faculty or administrative staff? 1 33c
d Scholarships or other financial assistance? d
e Educational policies? 33e
f Use of facilities?
g Athletic programs?
h Other extracurricular activities?
If you answered "Yes" to any of the above , please explain. (If you need more space , attach a separate statement.)
----------------------------------------------------------------------------------------------------------------------• y<.^ >
34a Does the organization receive any financial aid or assistance from a governmental agency
b Has the organization's right to such aid ever been revoked or suspended? 34b
If you answered "Yes" to either 34a or b, please explain using an attached statement.
35 Does the organization certify that it has complied with the applicable requirements of sections 4.01 through 4 05of Rev. Proc. 75-50. 1975-2 C B. 587. coverina racial nondiscrimination? If "No." attach an explanation 35
Schedule A (Form 990 or 990-EZ) 2005
Fletcher Allen Health Care Auxiliary 23-7003241
Schedule A (Form 990 or 990-EZ) 2005 Page 5
Lobbying Expenditures by Electing Public Charities (See page 9 of the instructions.)(To be completed ONLY by an eligible organization that filed Form 5768) Not Applicable
Check ► a q if the organization belongs to an affiliated group. Check ► b q if you checked "a" and "limited control" provisions apply
Limits on Lobbying Expenditures Affiliated group To be completedtotals for ALL electing
(The term "expenditures" means amounts paid or incurred.) organizations
36 Total lobbying expenditures to influence public opinion (grassroots lobbying) 36
37 Total lobbying expenditures to influence a legislative body (direct lobbying) 37
38 Total lobbying expenditures (add lines 36 and 37) 38
39 Other exempt purpose expenditures 39
40 Total exempt purpose expenditures (add lines 38 and 39) 40
41 Lobbying nontaxable amount. Enter the amount from the following table-
If the amount on line 40 is- The lobbying nontaxable amount is-
Not over $500,000 20% of the amount on line 40
Over $500,000 but not over $1,000,000 . $100,000 plus 15% of the excess over $500,000
Over $1,000,000 but not over $1,500,000 $175,000 plus 10% of the excess over $1,000,000 41
Over $1,500,000 but not over $17,000,000 $225,000 plus 5% of the excess over $1,500,000
Over $17,000,000 $1,000,000
42 Grassroots nontaxable amount (enter 25% of line 41) 42
43 Subtract line 42 from line 36. Enter -0- if line 42 is more than line 36 43
44 Subtract line 41 from line 38. Enter -0- if line 41 is more than line 38d 'e,
Caution : If there is an amount on either line 43 or line 44, you must file Form 4720 1, A, 4^
4-Year Averaging Period Under Section 501(h)
(Some organizations that made a section 501(h) election do not have to complete all of the five columns below.See the instructions for lines 45 through 50 on page 11 of the instructions.)
Lobbying Expenditures During 4-Year Averaging Period
Calendar year (or
fiscal year beginning in) ►(a)
2005(b)2004
(c)2003
(d)2002
(e)Total
45 Lobbying nontaxable amount
46 Lobbying ceiling amount (150% of line 45(e))
47 Total lobbying expenditures
48 Grassroots nontaxable amount
49 Grassroots ceiling amount (150% of line 48(e))
50 Grassroots lobbying expenditures
Lobbying Activity by Nonelecting Public Charities(For reporting only by organizations that did not complete Part VI-A) (See page 11 of the instructions.)
During the year, did the organization attempt to influence national, state or local legislation, including any
attempt to influence public opinion on a legislative matter or referendum, through the use of:Yes No Amount
a Volunteers 3
ement (Include compensation in expenses reported on lines c through h.)b Paid staff or mana 3g
c Media advertisements 3
or the publicd Mailin s to members legislators 3g ,,
or published or broadcast statementse Publications 3,
anizations for lobbying purposesf Grants to other or 3g
or a legislative bodygovernment officialsislators their staffsg Direct contact with le 3,,g ,
or any other meanslecturesconventions speechesh Rallies seminarsdemonstrations 3, ,, ,, ,i Total lobbying expenditures (Add lines c through h.) 0
If "Yes" to any of the above, also attach a statement giving a detailed description of the lobbying activi ties.
Schedule A (Form 990 or 990-EZ) 2005
Fletcher Allen Health Care Auxiliary 23--7003241
Schedule A (Form 990 or 990-EZ) 2005 Page 6
Information Regarding Transfers To and Transactions and Relationships With Noncharitable
Exempt Organizations (See page 12 of the instructions.)
51 Did the reporting organization directly or indirectly engage in any of the following with any other organization d
501(c) of the Code (other than section 501(c)(3) organizations) or in section 527, relating to political organizations
escribed
?
in section
a Transfers from the reporting organization to a noncharitable exempt organization of: Yes No
(I) Cash 51a (i ) 3
(ii) Other assets a ii 3
b Other transactions:
(i) Sales or exchanges of assets with a nonchantable exempt organization b i
(ii) Purchases of assets from a noncharitable exempt organization b (ii ) 3
equipment or other assets(iii) Rental of facilities b(iii) 3,,
(iv) Reimbursement arrangements b v 3
(v) Loans or loan guarantees b (y) 3
(vi) Performance of services or membership or fundraising solicitations b vi 3
or paid employeesmailing lists other assetsequipmentc Sharing of facilities c 3,, ,,
d If the answer to any of the above is "Yes," complete the following schedule. Column (b) should always show the fairgoods, other assets, or services given by the reporting organization. If the organization received less than fair mtransaction or sharing arrangement, show in column (d) the value of the goods, other assets, or services received-
marketarket v
value of thealue in any
Schedule A (Form 990 or 990-EZ) 2005
52a Is the organization directly or indirectly affiliated with, or related to, one or more tax-exempt organizations
described in section 501(c) of the Code (other than section 501(c)(3)) or in section 527? ► q Yes ® No
U 1
Fletcher Allen Health Care Auxiliary23-7003241
Form 990 FYE 4130/06
COST OF GOODS SOLD
Inventory - Beginning
Purchases
Inventory Available for Sale
Less : Ending Inventory
COST OF GOODS SOLD
GRANTS AND ALLOCATIONS
Statement #1
page 1 line 10b
46,669
345,592
392,261
(55, 833)
336,428
Statement #2
PART 11 LINE 22
Description
Fletcher Allen Health Care - Hospital Fund
Children's Miracle Network
Fletcher Allen Health Care - Fanny Allen Free Clinic
Pandora's Box
Fletcher Allen Health Care - Scholarship Fund
TOTAL GRANTS AND ALLOCATIONS
129,350
4,044
133,394
4 •
Fletcher Allen Health Care Auxiliary Statement #323-7003241Form 990 FYE 4130106Part 11 LINE 43
OTHER EXPENSESProgram
Description Total Services
Miscellaneous Expenses 14,448 14,448'
Cost of car seats and replacement costs 1,266 1,266
Advertising 805 805
Insurance 538 538
Storage 2,057 2,057
Utilities 2,672 2,672
Total 21,786 21,786,
FLETCHER ALLEN HEALTH CARE AUXILIARYFletcher Allen Auxiliary Gift Shop at MCHV Campus
Date Description Deprec & Yrs Cost
3/85 Display Units SL 10 yrs 530 00
5/85 Flower Cooler SL 10 yrs 3,85046
3/90 Computer/Pnnter SL 10 yrs 539 56
12/93 Charge Card Unit SL 10 yrs 585 00Disposal 10/2004 (585 00)2/99 Computer SL 10 yrs 2,18800
5/99 New Carpet SL 10 yrs 5,854 18
Disposal 10/2004 (5,854 18)
5/00 Cash Registers (2) SL 10 yrs 3,29620
10,404 22
23-7003241
STATEMENT 4
A/D 02 Exp Fv'03 A/D 03 Exp Fv'04 A/D 04 Exp Fy'05 A/D 05 Exp Fy'06 A/D 06
530 00 - 530 00 - 530 00 - 530 00 - 530 00
3,850 46 - 3,850 46 - 3,85046 - 3,850 46 - 3,850 46
539 56 - 539 56 - 539 56 - 539 56 - 539 56
492 00 59 00 551 00 34 00 585 00 - 585 00 - -
(585 00)
711 10 218 80 929 90 218 80 1,14870 218 80 1,367 50 218 80 1,586 30
1,756 25 585 42 2,341 67 585 42 2,92709 292 71 3,219 80 - -
(3,219 80)
659 24 329 62 988 86 329 62 1,31848 329 62 1,648 10 329 62 1,97772
8,538 61 1,192 84 9,731 45 1,167 84 10,899 29 841 13 7,935 62 548 42 8,484 04
Book Value 1,865 61 672 77 (49507) 2,468 60 1,920 18
FLETCHER ALLEN HEALTH CARE AUXILIARY 23-7003241
Fletcher Allen Auxiliary Gift Shop at Fanny Allen Campus
Depreciation Schedule
2005Date Description Deprec & Yrs Cost Deprec Exp
5/99 Renovations SL 10 yrs. 11,024.20 1,10242
Book Value
STATEMENT 5
2006A/D 05 Deprec Exp A/D 06
6,614.52 1,102.42 7,716.94
4,409.68 3,307.26
C \Documents and Settings \J\My Documents\FAHC work\taxes\Auxdiary\[2006 Aux XLS]FA Deprec
FLETCHER ALLEN HEALTH CARE AUXILIAF
Replays
Plant, Property and Equipment
Furniture and Fixtures Method
Telephone SLCash register SLShowcase SLRacks SLDisplay (Lady Shelburne) SLDisplay (Lady Shelburne) SLRacks SL
WasherValances & Rods2 Show racksDryerCarpet, tileSignVacuumDisplay rack
SLSLSLSLSLSLSLSL
Sign
Cash register
Shelving & furnitureBookcases
Racks, ShelvingFurnitureClothes Steamer
Leasehold Improvements
ImprovementsShelving
CarpetingConstructionShelvingSign
SL
SL
SLSL
SLSLSL
23-7003241
STATEMENT 6
4/30/2005Life Cost Accum Depr
10 Years 54 99 54 9910 Years 369 00 369 0010 Years 380 00 380 0010 Years 50 00 50 0010 Years 98 00 98 0010 Years 110 00 110 0010 Years 166 54 166 54
Subtotal 1,228 53 1,228 53
10 Years 175 00 175 0010 Years 65.97 65 9710 Years 52.48 52.4810 Years 150 00 150 0010 Years 2,87400 2,8740010 Years 199 50 199 5010 Years 135 46 135 4610 Years 5000 50 00
Subtotal 4,930 94 4,930 94
10 Years 37950 379 50
Subtotal 5,310 44 5,310 44
10 Years 665 00 532 00
Subtotal 5,975 44 5,842 44
10 Years 1,022 00 408 8010 Years 390 50 156 20
Subtotal 7,387 94 6,407 44
10 Years 671 40 201 4210 Years 695 75 208 7310 Years 251 43 75.43
Subtotal 9,006 52 6,893 01
1,823 77SL 10 Years 1,82377SL 10 Years 185 00
Subtotal 11,015 29
SL 7 Years 2,444 78SL 10 Years 750 00SL 10 Years 711 52SL 10 Years 541 00
Subtotal 15,462 59
VehicleSale of 2001 Dodge Dakota2001 Dodge Dakota ACRS
844 03181 25154 1654 10
10,042 83
(16,107 00) (11,797 50)5 Years 16,107 00 11,797.50
Subtotal 15,462 59 10,042 83
4/30/2006 4/30/2006Deprec Accum Depr
- 54 99- 369 00- 380 00- 50 00- 98 00- 110 00- 166 54
- 1,22853
- 175 00- 65 97- 52 48- 150.00- 2,874 00- 199 50- 135 46- 50 00
- 4,930 94
- 379 50
- 5,310 44
66 50 598 50
66 50 5,908 94
102 20 511 0039 05 195.25
207 75 6,61519
67 14 268 5669 58 278 3025 14 100 57
369 61 7,26262
1,82377
34925 1,193 2975.00 2562571.15 225 3154 10 108 20
937 61 10,980 44
15,462 59 Cost 15,462 59(10,042 83) A/D (10,980.44)
5,419 76 Book Value 4,482 15
y 4k •
Fletcher Allen Health Care Auxiliary Statement #723-7003241
Form 990 FYE 4/30/06Part III
Statement of Program Service Accomplishments
The Fletcher Allen Health Care Auxiliary's primary purpose
is to support the mission of Fletcher Allen Health Care,
a not for profit, in providing acute health care service
to the community regardless of ability to pay.
Statement #8
Statement of Program Service AccomplishmentsPart Ilia
Grants & Program
Deseription Allocations Services Total
Gift Shop Operations 211,539 211,539
Hospital Service and Contributions 133,394 3,527 136,921
Patient Library 492 492
Car Seat Rental Program 2,883 2,883
Replays - Second Hand Shop 136,440 136,440
TOTALS 133,394 354 , 881 488,275
1 •
Fletcher Allen Health Care Auxiliary Statement #923-7003241
Form 990 FYE 4/30/06
SCHEDULE A
Part III Line 2e
Grants were made to support Fletcher Allen Health Care,
the Auxiliary's supported organization.
See detail for Form 990, Part II , Line 22
Statement #10
Part III - Note:
Grants are made only to organizations qualified
under IRC section 170.
^p y a
Fletcher Allen Health Care Auxiliary Statement #1123-7003241Form 990 FYE 4130/06Balance Sheetpage 3 line 65
Beginning End ofOther Liabilities of Year Year
Sales Tax Payable 2,496 2,860
Salaries Payable 16,237 16,763
Other Liabilities 2,781 3,170
Total Other Liabilities 21,514, 22,793
page 3 line 64b Statement #12
Beginning End ofof Year Year
Note Payable - -
Form 8868 Application for Extension of Time To File an(Rev December 2004) Exempt Organization Return OMB No 1545-1709
Department of the Treasuryinternal Revenue Service 10- File a separate application for each return.
• If you are filing for an Automatic 3-Month Extension , complete only Part I and check this box . . . . . . . . ►• If you are filing for an Additional (not automatic) 3-Month Extension , complete only Part II (on page 2 of this form).Do not complete Part I! unless you have alread y been granted an automatic 3-month extension on a p reviousl y filed Form 8868.
Automatic 3-Month Extension of Time-Only submit original (no copies needed)
Form 990-T corporations requesting an automatic 6-month extension--check this box and complete Part I only . . . ► q
All other corporations (including Form 990-C filers) must use Form 7004 to request an extension of time to file income tax returns.Partnerships, REMICs, and trusts must use Form 8736 to request an extension of time to file Form 1065, 1066, or 1041.
Electronic Filing (e-file ). Form 8868 can be filed electronically if you want a 3-month automatic extension of time to file one of thereturns noted below (6 months for corporate Form 990-T filers). However, you cannot file it electronically if you want the additional(not automatic) 3-month extension, instead you must submit the fully completed signed page 2 (Part II) of Form 8868. For moredetails on the electronic filing of this form, visit www.irs.gov/efile.
Type or Name of Exempt Organization Employer identification number
print Fletcher Allen Health Care Auxiliary 23 7003241
File by the Number, street, and room or suite no It a P 0 box, see instructionsdue date for
111 Colchester Avefiling yourreturn Seeinstructions City, town or post office, state, and ZIP code For a foreign address, see instructions
Burlington , VT 05401
Check type of return to be filed (file a separate application for each return):
© Form 990 q Form 990-T (corporation) q Form 4720
q Form 990-BL q Form 990-T (sec. 401(a) or 408(a) trust) q Form 5227
q Form 990-EZ q Form 990-T (trust other than above) q Form 6069
q Form 990-PF q Form 1041-A q Form 8870
• The books are in the care of Fletcher Allen Health Care-----•• - - -------------------------------------------------- ------
Telephone No. ► (__802
-
) 847-1892 FAX No . lip- (_ - _802 ) 847-8035---...-----•-----
• If the organization does not have an office or place of business in the United States, check this box . . . . . ► q
• If this is for a Group Return , enter the organization's four digit Group Exemption Number (GEN) . If thisis for the whole group, check this box ► q . If it is for part of the group, check this box ► q and attach a list with thenames and EINs of all members the extension will cover.
1 I request an automatic 3-month (6-months for a Form 990-T corporation ) extension of time until -12/1-5 20 06,
to file the exempt organization return for the organization named above. The extension is for the organization's return for:
► q calendar year 20... or
. .......... . 05/01 20 05 , and ending 04/30 20 06.Op- 0 tax year beginning ............. 05101
2 If this tax year is for less than 12 months, check reason: q Initial return q Final return q Change in accounting period
3a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less any
nonrefundable credits. See instructions . . . . . . . . . . . . . . . . . . . . . . $ None
b If this application is for Form 990-PF or 990-T, enter any refundable credits and estimated tax payments
made. Include any prior year overpayment allowed as a credit . . . . . . . . . . . . . . $ None
c Balance Due. Subtract line 3b from line 3a. Include your payment with this form, or, if required, depositwith FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment System). Seeinstructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ None
Caution . If you are going to make an electronic fund withdrawal with this Form 8868, see Form 8453-EO and Form 8879-EO
for payment instructions.
For Privacy Act and Paperwork Reduction Act Notice , see Instructions . Cat. No 27916D Form 8868 (Rev 12-2004)
Form 8868 (Rev 12-2004) Page 2
• If you are filing for an Additional (not automatic) 3-Month Extension , complete only Part II and check this box ► qNote . Only complete Part II if you have already been granted an automatic 3-month extension on a previously filed Form 8868• If you are filing for an Automatic 3-Month Extension , complete only Part I (on page 1).
jiEM Additional (not automatic) 3-Month Extension of Time-Must File Origin I and One Copy.Type or Name of Exempt Organization Employer Identification number
File by the Number, street, and room or suite no If a P O box, see instructions For IRS use onlyextendeddue date forfiling the City, town or post office, state, and ZIP code For a foreign address, see instructionsreturn. Seeinstructions.
Check type of return to be filed (File a separate application for each return):
q Form 990 q Form 990-T (sec. 401 (a) or 408(a) trust) q Form 5227q Form 990-BL q Form 990-T (trust other than above) q Form 6069q Form 990-EZ q Form 1041-A q Form 8870q Form 990-PF q Form 4720
STOP: Do not complete Part 11 if you were not already granted an automatic 3-month extension on a previously filed Form 8868.
• The books are in the care of ►Telephone No. ► (----•----)---------------------------- FAX No. ► (---------- I-....-----------------------•
• If the organization does not have an office or place of business in the United States, check this box . . . . . . ► q• If this is for a Group Return , enter the organization's four digit Group Exemption Number (GEN) If this isfor the whole group, check this box ► q . If it is for part of the group, check this box ► q and attach a list with thenames and EINs of all members the extension is for.
4 I request an additional 3-month extension of time until ----------------------------------------- - 20----.5 For calendar year -------- or other tax year beginning------------------------ -20----,and ending ------------------------ ,20-----.6 If this tax year is for less than 12 months, check reason: q Initial return q Final return q Change in accounting period7 State in detail why you need the extension --------------------------------------------------------------------------••---------------
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8a If this application is for Form 990-BL, 990-PF, 990-T, 4720, or 6069, enter the tentative tax, less anynonrefundable credits. See instructions . . . . . . . . . . . . . . . . . . . . . . $
b If this application is for Form 990-PF, 990-T, 4720, or 6069, enter any refundable credits and estimatedtax payments made. Include any prior year overpayment allowed as a credit and any amount paidpreviously with Form 8868 . . . . . . . . . . . . . . . . . . . . . . . . $
c Balance Due. Subtract line 8b from line 8a. Include your payment with this form, or, if required, depositwith FTD coupon or, if required, by using EFTPS (Electronic Federal Tax Payment System). See instructions $
Signature and VerificationUnder penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and beliefit is true, correct, and complete, and that I am authorized to prepare this form
Signature ^^ Title ► Ale. €,C?--. Date -V/
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KV Noti t Applicant-To Be Completed by the IRSq We have approved-ttig application Pleas ach this form to the organization's return
q We have not approved this application However, we have granted a 10-day grace period from the later of the date shown below or the duedate of the organization's return (including any prior extensions) This grace period is considered to be a valid extension of time for electionsotherwise required to be made on a timely return Please attach this form to the organization's return
q We have not approved this application After considering the reasons stated in item 7, we cannot grant your request for an extension of timeto file We are not granting a 10-day grace period
q We cannot consider this application because it was filed after the extended due date of the return for which an extension was requested
q Other --•----------------------------------------•------------------••-•-----------------------------•-•-•-----------••---------------------
ByDirector Date
Alternate Mailing Address - Enter the address if you want the copy of this application for an additional 3-month extensionreturned to an address different than the one entered above.
Name
Type or Number and street (include suite , room , or apt . no.) or a P.O. box number
City or town , province or state, and country (including postal or ZIP code)
Form 8868 (Rev 12-2004)
